Right hepatectomy - step by step description for surgeon

• Right subcostal with midline extension (hockey stick incision)

• Dissect falciform ligament until right hepatic,middle and left hepatic seen inserting in to IVC (dissection of suprahepatic IVC)

• Dissect groove between right and middle-left

Suprahepatic IVC

Dissection ofGroove betweeenRight and middle left hepatic veins

Dissected veins

MOBILIZATION OF LIVER

• After that right lobe is mobilized from it’s ligamentous attachments as shown in figures.

• Several short hepatic veins corsing from liver to IVC needs to be ligated.

• Idea should be to elevate right lobe of liver from the IVC.

Dissecting Right Hepatic Vein

• Make a good groove between right and middle-left during top dissection.

• As shown in first figure, you will encounter hepato- caval ligament.

• Dissect it and divide it between clamp (few small veins may run through it)

• After that you will find right hepatic vein. Create tunnel behind ir and connect it to the initial groove you have created. Now Loop It.

Hepatocaval or Makuchhi’s ligament

Portal dissection• DO Fundus first cholecystectomy.• Tie cystic duct. Keep the threads long (act as retractor.)• By retracting you will have idea where the cbd is.• Retract CBD with ties.• Now try to dissect hepatic artery by pulsation (you will find it until it

course anterior to the CBD)• Dissect hepatic artery, clamp and feel pulsation of left hepatic artery. IF ok.• Suture ligate and cut it.• Posterior to it you will Find portal vein and its right and left branch.

Dissect right portal vein loop it and cut it with staplers or suture ligate it or close the remaining end with prolene 5-0.

• While dissecting right portal vein you will find one or two branches going in to caudate process. Ligate it.

Parechchymal Transection

• Now you will find transection line on the liver surface mark it.

• Extend it up to junction of right and left bile duct.(you will get idea by lowering hilar plate)

• Transect it by any method. (clamp crush,cusa,harmonic whatever you have)

• You can ligated any horizontal small vessels going to right side.(middle hepatic vein runs vertically)

Hanging Maneuver

• Now pass Ryle’s tube below right hepativ vein that you dissected. Bring it anterior to IVC and take it out through porta and lift liver by holding both the end of ryle’s tube.(assistant holds the below end and upper end can be secure with artery forceps etc.

• Will help and lifting the liver and prevent injury to IVC

• At last loop the right bile duct and cut it and tie it with continuous PDS 4-0,5-0,6-0 or stapler it.

• Deliver the specimen out.• Secure hemostasis at the cut surface.• ( all these pictures are screenshots from

blumgart video atlas)